Pressure Injury Survey Guide

Conduct the Study - Chart Review

Pressure Injury Prevention in Use for “At Risk” Patients

Review the medical record of each patient who is at pressure injury risk to determine whether the patient received appropriate interventions to prevent pressure injury development. Interventions should be “risk-based” (i.e. address the modifiable risks identified in risk assessment scale sub-scores and additional risk factors)

It is crucial that pressure injury prevention care be documented in the patient record.

  • Provides evidence that prescribed interventions were implemented
  • Provides evidence for the continuity of patient care

Experts also recommend that the documentation of pressure injury prevention care be validated by observations of bedside practices.1

For NDNQI, documentation of pressure injury interventions received within 24 hours of the survey is considered evidence of their use.

  • Physician and nursing orders are not adequate evidence of prevention in use
  1. Bergquist-Beringer, S., Dong, L., He, J., & Dunton, N. (2013). Pressure ulcers and prevention among acute care hospitals in the United States. Joint Commission Journal on Quality and Patient Safety, 39(9), 404-414.
  2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (E. Haesler Ed.). Osborne Park, Western Australia: Cambridge Media.